Educational interventions for cervical cancer prevention: a scoping review

ABSTRACT Objectives: to identify, map and describe characteristics of educational interventions for cervical cancer prevention in adult women. Methods: a scoping review conducted on eleven databases and the gray literature, including studies that described educational interventions aimed at preventing cervical cancer in adult women. Results: thirty-three articles with 151,457 participants were analyzed. The most used educational strategies were participatory discussions and educational leaflets. Most of the interventions took place in a single session, ranging from 40 to 60 minutes. The most used theoretical model in interventions to improve women’s compliance with Pap smear was the Health Belief Model. Conclusions: group discussions, lectures and educational brochures can increase knowledge and reduce barriers to cervical cancer prevention. Theory-based and culturally sensitive interventions can have a positive impact on women’s health.


INTRODUCTION
Cervical cancer (CC) is the fourth most common cancer among women in the world, with an estimated 604,000 new cases and 342,000 deaths in 2020 (1) .About 90% of new cases and deaths occur in low-and middle-income countries (1) .CC mortality can be reduced through regular examinations and early treatment (2) .However, inadequate infrastructure and funding difficulties to implement CC control strategies are limiting in developing countries (3) .
Periodic Pap smear testing continues to be the most adopted strategy for the screening of precursor CC lesions (4) .The World Health Organization (WHO) recommends performing Papanicolaou smear every three years in women aged 25 to 64 years after two negative tests with an annual interval (5) .
Awareness of the benefits of CC screening, diagnostic methods, the importance of early follow-up and treatment are among the main factors that encourage women to perform Pap smears (6) .Higher return rates are expected for well-informed women, who more easily adhere to the recommendations of health professionals and find innovative ways to deal with the disease, being less susceptible to complications (7) .
Several studies have tested educational strategies to strengthen the attitudes, practices and knowledge of women candidates for CC screening as well as to reduce barriers to compliance with these programs (8)(9)(10)(11)(12)(13)(14) .Among these theoretical models, we can mention the Health Belief Model (HBM) (15) , the Motivation Protection Theory (MPT) (16) and the Social Cognitive Theory (SCT) (17) .
Despite CC screening campaigns, compliance remains low in most developing countries.Thus, it is important to know the educational intervention characteristics that have been used to improve CC prevention.

OBJECTIVES
To identify, map and describe the characteristics of educational interventions for CC prevention in adult women.

METHODS
This is a scoping review conducted according to the JBI methodology, described in the JBI Reviewer Manual 2020 (18) , and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) recommendation (19) , seeking to answer the following research question: what is the scientific evidence on educational interventions for CC prevention in adult women?The protocol for this review was registered on the Open Science Framework (OSF) platform and can be consulted at the link: osf.io/4zgex.
The search strategy organization used the acronym PCC, with P for population, C for concept and C for context (18) .Population consisted of studies involving adult women (age ≥18 years) with no previous diagnosis of CC.The key Concept of this review was composed of studies that detailed the characteristics of educational interventions aimed at preventing CC (elements, mode of delivery, dose, educational materials, educational content, type of theory).Context was primary care, hospitals, clinics, community centers, schools or churches.
The search strategy aimed to locate published and unpublished studies, and occurred in two stages.In the first one, a search was carried out in the MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, followed by the analysis of title and abstract words and study descriptors with the terms as follows: "Cervix cancer; cervical cancer; Uterine Cervical Neoplasms; screening; Prevention and control; Papanicolaou test; Pap test; Pap smear; education; intervention".
In the second stage, a new search using all identified keywords and descriptors was carried out in the previously described databases.To develop the search strategy, we had the help of an experienced librarian.The searches used modified controlled vocabulary for each database.
Data collection took place between June 7 and August 14, 2022, in the PubMed/MEDLINE, Scientific Electronic Library Online (SciELO), PsycINFO, Cochrane Library databases, through Virtual Health Library (VHL) portal; in the Latin American and Caribbean Literature in Health Sciences (LILACS) and Nursing Database (BDENF) databases, through the Coordination for the Improvement of Higher Education Personnel (CAPES -Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) portal; and in the CINAHL, Web of Science, Embase, Scopus databases.Unpublished studies were searched in the gray literature (Google Scholar, Catalog of Theses and Dissertations CAPES -Brazil and Brazilian Registry of Clinical Trials -ReBEC, Digital Library of Theses and Dissertations (BDTD).
This review included qualitative and quantitative studies focusing on educational interventions aimed at preventing CC in adult women.Qualitative studies of any theoretical and methodological approaches were considered as well as studies published in English, Spanish or Portuguese, with no date limit.
Intervention studies that addressed other types of cancer (breast cancer, colon cancer, colorectal cancer and others), studies that used only an invitation letter or reminder for Pap smear, without educational content based on literature or theory, were excluded.Systematic or integrative reviews and study protocols were also excluded, as they did not present in detail the elements of the educational intervention (method of delivery, dose, educational materials, intervenor).Disagreements were resolved by discussion between the two reviewers and, when necessary, by a third reviewer.
All titles and abstracts retrieved in searches were pooled in the Mendeley ® reference management database for identification and exclusion of duplicates.For selection and assessment of sample studies, the Rayyan software was used (20) .Study preselection was performed by reading the title and abstract by two reviewers independently, based on established inclusion criteria.
Data extraction from the studies included in the review was performed using a standardized data extraction tool (Appendix 2).General data extracted included data on the authors, year of publication, objectives, methods, study design, outcomes, target population characteristics (age, race/ethnicity), intervention characteristics (educational strategies, mode of delivery, dose, intervenor), theoretical structure, type of intervention (individual, group or multicomponent) and main results of the intervention.

RESULTS
Figure 1 expresses the search and selection results presented by the PRISMA-ScR flowchart (19) .After reading, some studies were excluded for not describing the elements of the intervention and the type of theory used, leaving 33 articles for analysis.
The population of most of analyzed studies consisted of women aged 21 to 65 years, immigrants, Hispanic/Latina, and from rural environments, with a history of low adherence to Pap smear, no previous history of CC, married, non-pregnant, who had never received health education about CC and without health insurance.The total sample size in this review was 151,457 (Chart 1).
Education through telephone interviews was also used in some studies to provide explanations about CC and its risks, the purpose of Pap smear test, the importance of correct frequency of testing, pre-examination care, in addition to information about returning to access post-exam result (25,28,35) .
Another strategy used was the PLNav, used to help women access health services through professionals from the same community who work, speak the same language and/or come from the same context as the target population.This format was applied in studies that demonstrated an increase in knowledge about CC screening and screening among participating women (23,34,40) .
The content of the educational activities used in the interventions addressed themes related to CC, including risk factors, ways of preventing the disease and possible symptoms, with emphasis on the importance of performing Pap smear.Moreover, many interventions addressed the benefits and barriers in relation to Pap smear, including knowledge, attitudes, beliefs and information about access to health services.Some activities also emphasized the relationship between CC and Human Papillomavirus (HPV) infection, healthy lifestyle behaviors including healthy nutrition, physical activity, and weight management.
Regarding the theoretical model used, the most frequent one as a basis for the intervention was the HBM, which aims to increase knowledge, improve attitudes, broaden the perception of the benefits of the test and health motivation, in addition to reducing the barriers to performing Pap smear, factors that can contribute to CC prevention (7)(8)10,13,21,26,(31)(32)35,42) .
The Protective Motivation Theory was used in two studies and incorporates the cognitive process into a conceptual framework that describes intention and behavior (24,39) .Two studies used mapping principles, which consider the needs empirically observed in the target population (33,36) .In these studies, the intervention was applied by CHW (33,36) .CHWs trained the women under their cover in person using educational pamphlets during 3 sessions over 21 days.
A23 (22)  AMIGAS intervention included a video drama using models to discuss barriers and facilitators to CC screening, a flipchart reviewing video information, games and activities, including a set of cards to understand a woman's stage of change, in addition to a contract sheet titled "my promise".
Study analysis showed that educational strategies, based on theories and culturally sensitive, can be used in combination for CC prevention, with emphasis on group discussions and lectures.Educational interventions that address knowledge about CC, barriers to screening and the importance of performing Pap smear seem to influence women's health beliefs and behavior.Educational interventions that rely on the collaboration of CHW can contribute to the reduction of barriers to screening.

DISCUSSION
CC is still common in women.This review analyzed thirty-three studies that used educational interventions aimed at CC prevention in women aged ≥18 years, in any context of care.
In the present research, the discussion sessions and the educational leaflets appeared combined with each other, or in a complementary way to other methodologies such as videos, lectures, telephone calls, among others.A systematic review that assessed the effects of educational interventions on CC screening behavior showed that the different methods used improved prevention behaviors among women (46) .
Studies that used video as an educational strategy showed a significant increase in CC knowledge.Participating women reported greater confidence in scheduling Pap smear, suggesting that video can be a potentially useful means of communicating health information (22)(23)(29)(30)(33)(34)38,43) .
Phone call was also a strategy used to provide information about CC (28,35) or as a form of invitation to women who did not initially respond to the screening test (25) .Consistent with a scoping review, telephone contact increased attendance at the health service for performing Pap smear (47) .
The content of the educational activities used in the analyzed studies is similar to the findings of a systematic review that concluded that the interventions mainly emphasize CC, Pap smear and HPV (48) .Effective educational programs targeting CC awareness need sophisticated and comprehensive planning and assessment of target audience needs, such as level of knowledge, beliefs, attitudes and behaviors.
In the present study, most participants were Latino or from rural communities.Latin women expressed better response to educational interventions; however, they were more likely to be diagnosed at an advanced stage of the disease, due to relatively low screening rates, poorer quality of life, and lack of health insurance (49) .Women from rural areas presented a number of barriers to obtaining health care, such as travel distance, transportation difficulties and access to specialized care (49) .
Studies using the HBM indicated that providing information on CC risk factors and early detection are crucial elements to increase the intention to perform CC screening and that educational interventions delivered by CHWs helped to reduce CC disparities among women.women from different backgrounds (7)(8)13,21,26,(31)(32)35,42) .
Using educational booklets can be effective in increasing screening when the objective is to reach many women, with little or no knowledge about CC (26) .On the other hand, providing individual information over the phone, explaining the importance of the subject and making a personal invitation can be more effective strategies in reducing barriers (26) .
A study revealed a significant increase in screening rates in CHW-led interventions, which could be a useful approach as it uses trusted peer relationships to provide education and promote healthy behaviors, with an emphasis on CC prevention (42) .
The theoretical model most used by the studies included in this review was the HBM, similar to data observed in a systematic review and meta-analysis that showed that this model can be effective in promoting Pap smear compliance (50) .

Study limitations
The present study presents as a limitation the lack of checking the references of analyzed studies to locate additional studies.

Contributions to nursing
Educational interventions have the potential to increase knowledge, change health beliefs and reduce barriers to CC prevention.Theory-based and culturally sensitive interventions appear to have a positive impact on women's health.This research revealed low participation of nurses in educational intervention programs and it is questioned whether the participation of this professional could contribute to reducing barriers to health prevention behaviors.This hypothesis should be tested in future studies.

CONCLUSIONS
Study analysis showed that different educational strategies can be used in combination for CC prevention, with emphasis on group discussions and lectures.Educational leaflets were used as support material.The content of the interventions emphasized knowledge about CC, barriers to screening and the importance of performing Pap smear.
Most of studies indicated benefits of CHW's performance and few had nurses as an intervenor.Studies that test theory-based, culturally sensitive educational interventions, with nurses as the intervenor, are needed to assess the impact of these interventions on women' s health.

FUNDING
This study was carried out with the support of CAPES -Brazil -Financing Code 0001.

Figure 1 -
Figure 1 -Study search flowchart based on Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews, Coari, Amazonas, Brazil, 2022

Chart 1 -
Description of the main characteristics of analyzed studies Focus group discussions with 6 to 10 individuals on quality of life, CC history, behaviors, lifestyle and beliefs.The women received 3 sessions of 60 minutes on cancer, HPV infection, healthy lifestyle and behaviors, including healthy nutrition, physical activity and weight management.
Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation-Political, Regulatory and Organizational Constructs in Educational and Environmental Development; AMIGAS -Helping Women with Information, Guidance and Love for their Health; SCT -Social Cognitive Theory.CCS -Cervical cancer screening.